Daniel H. Wiznia

BACKGROUND: For patients in lower socioeconomic groups who are unable to take time off from work, afford transportation to a clinic, or who live in rural locations, telehealth appointments have been found to improve access to care. Given how knee osteoarthritis disproportionately impacts patients in lower socioeconomic groups, we sought to evaluate the availability of telehealth appointments in orthopaedic surgery practices for patients with knee osteoarthritis with private or public (Medicaid) insurance. METHODS: A secret shopper methodology was utilized for a scenario designed to measure access to telehealth appointments for patients with knee osteoarthritis. The caller asked questions regarding the availability and wait times for telehealth and in-person appointments for both new visits and follow-up visits. Separate calls were made for private and public insurance. Descriptive characteristics and univariate tests were used for analysis. RESULTS: For initial new patient consults, 4.3% (13/304) of practices accepting private insurance offered telehealth and 3.6% (7/196) of practices accepting Medicaid offered telehealth. For follow-up visits, 39.8% (121/304) of practices accepting private insurance offered telehealth, and 40.3% (79/196) of practices accepting Medicaid offered telehealth. No differences were found in the availability of telehealth services for patients with Medicaid compared to patients with private insurance. DISCUSSION: Telehealth is an underutilized but viable option for patients who are considering knee arthroplasty, especially for follow-up appointments. Implementing telehealth follow-up appointments can be beneficial to patients and surgeons. Further research should examine the barriers that limit the availability of telehealth in arthroplasty clinics and how a lack of musculoskeletal telehealth services, especially for patients of lower socioeconomic status, may affect access to osteoarthritis care.

INTRODUCTION Functional bracing is a common non-operative treatment for humeral shaft fractures. The effects of patient-specific soft tissue characteristics on fracture site biomechanics during bracing are poorly understood and may alter healing. This study leveraged finite element analysis (FEA) to characterize the impact of arm diameter and muscle-adipose composition on fracture site strain during bracing. In conjunction with other factors, researchers and clinicians may apply these findings toward optimizing outcomes in patients with humeral shaft fractures. METHODS Nine humerus FEA models were constructed with concentric cylindrical tubes representing fractured diaphyseal bone, muscle, adipose, and a plastic brace. Models had varying arm diameters (small, medium, and large, based on institutional data) and muscle-to-adipose tissue ratios (25%/75%, 50%/50%, 75%/25%). To simulate bracing and physiological bending movements, a uniform radial pressure (5.33 kPa) was applied to the brace, and a lateral force (40 N) was applied to the distal humerus with the proximal end fixed. Fracture site strain values were computed for each arm configuration. FEA findings were validated with biomechanical testing of a cadaveric arm that was braced and subjected to the same bending forces. RESULTS For a specific arm size, an increase in adiposity, as indicated by a lower muscle-to-adipose ratio, resulted in increased Perren strain values at the simulated fracture site. Furthermore, at a given ratio of muscle-to-adipose, an increase in arm size corresponded to a decreased level of strain experienced at the fracture site. Cadaveric biomechanical testing yielded comparable strain values to FEA models of similar arm composition. DISCUSSION These findings suggest that smaller diameter arms and increased adipose levels may increase fracture instability during functional brace treatment of humeral shaft fractures. Further, these findings may inform patient selection for functional bracing versus surgery for humeral shaft fractures or guide modifications to functional brace design.

Osteoarthritis (OA) lacks effective disease-modifying therapies. Nav1.7 has recently been identified as a regulator of both chondrocyte metabolism and pain, establishing it as a dual-acting therapeutic target in OA. This study evaluated lacosamide (LCM) as a disease-modifying candidate and developed a cartilage-targeted delivery strategy to enhance its translational potential. Sodium channel inhibitors (carbamazepine, oxcarbazepine, and LCM) were evaluated in primary human OA chondrocytes, cartilage explants, and a murine DMM model with systemic or intra-articular administration. Pain behavior was assessed by von Frey and open-field testing. A collagen II–based thermoresponsive hydrogel was developed for sustained intra-articular delivery, and outcomes were assessed by histology, immunohistochemistry, ELISA, and gene expression analyses. LCM was the most potent inhibitor in suppressing IL-1β–induced catabolism and promoting anabolism in human chondrocytes, showing greater efficacy at lower concentrations than carbamazepine or oxcarbazepine. Systemic LCM reduced cartilage degeneration and pain in murine OA and outperformed carbamazepine at equivalent doses, while intra-articular administration achieved superior protection and analgesia at one-tenth the dose. Mechanistically, LCM increased HSP70 and midkine secretion to drive anabolic and anti-catabolic responses. Sustained delivery via a collagen II-based hydrogel prolonged joint retention and enhanced therapeutic durability. Together with its clinical efficacy in Nav1.7 mutation–related neuropathy, these findings underscore LCM's translational potential as a dual-acting disease-modifying therapy for OA. LCM is a dual-acting Nav1.7 inhibitor that alleviates pain and modifies OA progression. Collagen II–based intra-articular delivery enhances efficacy and supports clinical translation as a noninvasive, non-opioid disease-modifying therapy. • Lacosamide modulates chondrocyte metabolism through Nav1.7 inhibition. • Lacosamide outperforms carbamazepine in protecting cartilage and reducing OA pain. • Collagen II–based hydrogel enables sustained intra-articular LCM delivery. • Hydrogel-released LCM provides long-lasting structural and analgesic benefits in OA. • Combining Nav1.7 inhibition with biomaterial delivery offers a disease-modifying OA therapy.

PURPOSE: For many, the emergency department (ED) serves as a critical entry point into the healthcare system. The purpose of this study was to investigate whether race, ethnicity, gender, or insurance were associated with hospital admission from the ED in the setting of an orthopaedic emergency. METHODS: This retrospective cohort analysis included all patients who presented to the ED with an orthopaedic emergency during a one-year period. Injury data were collected from an internal database of orthopaedic consultations. Injury verification, as well as admission status, race, ethnicity, age, gender, body mass index (BMI), and type of insurance were extracted from the medical record. RESULTS: A total of 4328 patients were included. On univariate analysis, older patients (mean age 58, rather than 52, P < 0.01), White as compared to Black (P < 0.01), and ethnically non-Hispanic patients (P < 0.01) were significantly more likely to be admitted to the hospital. On multivariate analysis that controlled for type of orthopaedic injury, White race, Medicaid or no insurance, and older age were significantly predictive of orthopaedic admission (all P < 0.05). On marginal analysis that accounted for type of orthopaedic injury, a White, male patient was noted to have a 10% higher probability of admission (49%, P > 0.01) following orthopaedic evaluation than a Black, female patient (39%, P > 0.01). CONCLUSIONS: This study demonstrates that even accounting for type of orthopaedic injury, race, age, and insurance are independently associated with hospital admission in the setting of orthopaedic emergencies.

Background: Timely administration of oral medications is a significant inpatient challenge, particularly in the context of postoperative pain management with limited nursing resources. Delays in delivering non-opioid analgesics, such as acetaminophen, can result in poorly controlled pain and increased opioid use. Methods: To address this gap, we developed the Patient-Controlled Oral Liquid Dispenser (P-COLD), a novel bedside device that enables patients to self-administer non-controlled liquid medications within programmable safety parameters. The system integrates a hospital-grade intravenous patient-controlled analgesia (PCA) pump into a secure, 3D-printed housing that delivers precise doses of medication into a bedside cup upon patient request. Results: The P-COLD was validated through laboratory testing and simulated-use evaluations without deployment in clinical patient care. Dose accuracy testing demonstrated consistent delivery within ± 5% of target volume. Simulated usability testing with healthy volunteers confirmed reliable patient operation with minimal instruction. Nursing staff successfully completed training and setup protocols, and time-motion analyses indicated potential reductions in workflow interruptions and nursing burden during as-needed (PRN) medication delivery. Conclusion: The P-COLD was designed to enable patient-initiated delivery of non-controlled oral liquid medications without IV access and without requiring nurse presence at the bedside for each dose. Validation testing in the laboratory and through simulated use demonstrated accurate dosing, reliable usability, and favorable simulated workflow performance. Plain Language Summary: In hospitals, patients often have to wait for a nurse to bring them medicine such as acetaminophen for pain or fever. These delays can leave patients in pain and lead to greater use of opioids to manage symptoms. We created a new device, called the Patient-Controlled Oral Liquid Dispenser (P-COLD), that lets patients safely take certain liquid medicines by themselves at the bedside. The device uses a hospital pump placed inside a secure case. When the patient presses a button, the pump delivers a measured dose of medicine into a cup. Safety limits are built in so patients cannot take too much. In testing, the device gave the right dose every time. Nurses and pharmacy staff were able to set it up quickly, and patients easily learned how to use it. The P-COLD may improve comfort, reduce delays, and decrease the need for as many opioids by making timely, safer medicines available at the bedside. The platform is designed to support delivery of a range of non-controlled oral liquid medications, including antipyretics, antiemetics, bowel regimens, and electrolyte supplements. Keywords: medical device design, oral solution medication delivery, patient-controlled analgesia, postoperative pain management, nursing staffing

Background Health-related social needs (HRSNs) are the individual-level adverse social conditions that negatively impact a person's health. This study characterizes the association of HRSNs with patient-reported outcomes and adverse events following total hip (THA) and knee arthroplasty (TKA). Methods This single-institution cross-sectional study utilized the Centers for Medicare & Medicaid Services HRSN Screening Tool. In-person interviews captured HRSNs, patient-reported outcome measures, and demographic data from postoperative THA and TKA patients in an academic arthroplasty practice. Charlson Comorbidity Index, American Society of Anesthesiologists scores, discharge data, and 90-day complications were collected via chart review. Regression analysis was used to determine associations between HRSNs and outcomes. Results Among 190 patients, food insecurity had a significant association with reoperation (odds ratio (OR) = 5.78, 95% confidence interval 1.44-23.2, P = .013). Patients with food and transportation HRSNs had significantly worse postoperative physical function, pain, and mobility (all P < .05). Black patients had significantly higher odds of visiting the emergency department (OR = 2.15, 95% CI 1.10-4.20, P = .025) or being readmitted (OR = 2.70, 95% confidence interval 1.11-6.58, P = .029) within 90 days postoperation compared to White patients. Conclusions Food insecurity was associated with increased odds of reoperation, and food insecurity and transportation were associated with worse patient-reported outcomes following THA and TKA. Black patients had increased risks of readmission and emergency department visits. These findings highlight the critical impacts of HRSNs on THA and TKA outcomes and underscore the need for targeted interventions addressing HRSNs to improve postoperative recovery and health-care equity.

Background Health-related social needs (HRSNs) are mandatory reporting measures per the Centers for Medicare & Medicaid Services. We sought to assess the prevalence of HRSNs and associations with clinical presentation among preoperative hip and knee osteoarthritis patients. Methods This prospective single-institution cross-sectional study assessed HRSNs (living situation, food, transportation, utilities, safety, financial strain, substance use, and mental health); Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Mobility, Pain Interference scores; and demographics (sex, race, education, income, household size, marital status) via in-person interviews in an academic arthroplasty practice. Kellgren-Lawrence Osteoarthritis Score, Charlson Comorbidity Index, and insurance were also determined. Odds of HRSNs by demographics were analyzed using logistic regression and relationship between HRSNs and PROMIS scores was determined by weighted least square linear regression. Results The study included 253 patients. Prevalences of each HRSN were 15% for living situation, 13% for food insecurity, 11% for transportation, 4% for utilities, 0.4% for safety, 58% for mental health, 31% for substance use, and 27% for financial strain. Black patients and patients on Medicaid had higher HRSN prevalences. PROMIS scores were significantly worse in patients with HRSNs, particularly for living situation, financial strain, and mental health domains ( P < .05 for Physical Function, Mobility, and Pain Interference scores in all these domains). Conclusions HRSNs are significant among hip and knee osteoarthritis patients and disproportionately high for Black and Medicaid patients. Patients with HRSNs presented with significantly worse PROMIS scores across Physical Function, Mobility, and Pain Interference domains, highlighting a healthcare disparity in this population.

OBJECTIVE: Tibial tuberosity to trochlear groove (TT-TG) distance serves as one of the main metrics for patellofemoral instability (PFI) surgical decision-making. The purpose of this study is to split TT-TG into translational (caused by bony morphology) and rotational (external tibiofemoral rotation) components, elucidate how those two components relate to each other, and determine how the components differ between recurrent PFI patients and controls. METHODS: Computed tomography (CT) scans of PFI patients with at least two reported dislocation events, seen by our institution's orthopedic department, were retrospectively acquired. Control CT scans were acquired from the Multicenter Osteoarthritis Study (MOST). Three-dimensional (3D) landmarks were placed on the distal femora and the proximal tibias. TT-TG, its rotational and translational components, and tibiofemoral rotation were algorithmically calculated from these landmarks. The two cohorts' means were compared using Mann-Whitney U-tests. Pearson coefficients were used to evaluate the correlation between the TT-TG components. The reliability of the measurements was evaluated with intraclass correlation coefficients (ICCs). The minimal sample size for a power level of 0.80 was calculated with an a priori sample size calculation. RESULTS: ​= ​0.29). Predictive ICCs for the four measurements ranged from 0.82 to 0.99. CONCLUSION: TT-TG can be split into (1) a translational component, primarily dependent on bony morphology, and (2) a rotational component, caused by external tibiofemoral rotation, both of which can lead to an elevated TT-TG measurement independently of each other. The rotational component is the primary factor for differences observed between PFI patients and controls but might vary between consequential patient scans. Our findings emphasize the importance of personalized treatment strategies tailored to individual patient profiles in treating patellar instability and will aid in more accurately targeted selection of surgical methods addressing either or both translational or rotational components of TT-TG. LEVEL OF EVIDENCE: III Case-Control study.

Background: Total joint arthroplasty is an effective intervention for end-stage joint disease, but carries elevated risks for patients with comorbidities and those from historically marginalized populations. Preoperative risk management programs are designed to mitigate these risks by optimizing patient health prior to surgery. This study evaluated the impact of such a program on postoperative outcomes at a single academic institution, with attention to racial and ethnic minorities and patients with public insurance. Methods: We conducted a retrospective cohort study of 2748 patients who underwent total hip or knee arthroplasty between 2019 and 2021 at a single academic institution. Of these, 1548 patients received preoperative optimization targeting modifiable risk factors such as diabetes, obesity, and anemia, while 1200 followed standard preoperative protocols. Outcomes assessed included length of stay, prosthetic joint infection, 30- and 90-day readmissions, and emergency department (ED) visits. Patients were stratified by race/ethnicity, insurance type, and American Society of Anesthesiology physical classification. Results: = .01). There were no significant differences between groups in length of stay, readmissions, or overall ED visit rates. Black patients experienced higher ED utilization within 90 days postoperatively, regardless of optimization status. Medicaid patients with severe systemic disease had the highest rates of prosthetic joint infection (3.8%), and optimization was not associated with improved outcomes in this group. Patients with American Society of Anesthesiology physical classification ≥3 had increased ED visits postoperatively despite optimization. Conclusions: Preoperative risk management did not consistently improve outcomes, particularly among patients with greater comorbidity burdens or those facing socioeconomic disadvantage. These findings support the need for tailored optimization strategies that address both clinical risk and social determinants of health.

Osteoarthritis (OA) and intervertebral disc degeneration (IVDD) are degenerative musculoskeletal disorders characterized by degeneration of cartilaginous tissues and inflammation. While inflammation is implicated in the pathogenesis of OA and IVDD, and cytosolic phospholipase A2 (cPLA2) is a key mediator of inflammation, direct evidence linking cPLA2 to chondrocyte homeostasis and cartilage degeneration is lacking. This study aims to investigate the role of cPLA2 in chondrocytes and its contribution to the development of cartilage degenerative conditions such as OA and IVDD. Here, single-cell RNA sequencing was used to examine cPLA2 expression in chondrocytes. To explore its importance in chondrocytes and OA/IVDD, various cell-based assays and genetically modified mouse models with age-related and surgically induced OA/IVDD were employed. Furthermore, the therapeutic potential of fexofenadine, an over-the-counter drug recently identified as a cPLA2 inhibitor, was explored in these models. cPLA2 is predominantly expressed in prehypertrophic chondrocytes, characterized by elevated levels of cartilage degeneration markers and senescence-related genes. Genetic deletion and pharmacological inhibition of cPLA2 reduced inflammation induced catabolic activity and senescence in chondrocytes, as well as cartilage degeneration in various OA and IVDD models. This study identifies cPLA2 as a pivotal driver of cartilage degeneration and senescence in OA and IVDD, highlighting its potential as a dual-action therapeutic target that suppresses both inflammation and senescence to preserve cartilage integrity. These findings position cPLA2 as a promising candidate for developing disease-modifying therapies for cartilage degenerative conditions such as OA and IVDD.

INTRODUCTION Posterior malleolus fractures are frequently associated with varying degrees of comminution. This comminution often leads to osteochondral fragment loss from the posterior articular surface of the tibial plafond. The purpose of this study is to use finite element modeling to determine whether osteochondral defects at the posterior malleolus fracture interface significantly influence tibiotalar contact stress. METHODS 3D models of 10 randomly selected patients were created of the tibia and talus from CT scans. A layer of cartilage was added to simulate contact at the tibiotalar joint. Different circular osteochondral defects were modeled at the fracture interface 3 mm, 5 mm, 10 mm in diameter. Two sizes of fractures were modelled (5 mm and 10 mm), from the posterior-most point on the articular tibial surface. Models with fractures and without osteochondral defects, were tested as controls. Models were loaded in finite element software under single-leg-stance at average body weight. Scenarios were repeated for maximal dorsiflexion and plantarflexion. Differences between the sizes of osteochondral defects across different fracture sizes for each ankle range of motion scenario were determined. RESULTS No significant differences in maximum articular contact stresses were observed between different sized osteochondral defect sizes in the 5 mm fracture size and ankle range of motion scenarios. However, significant differences in maximum articular contact stresses were observed between different sized osteochondral defect sizes with 10 mm fracture sizes. These differences were observed in neutral and dorsiflexion, but not in plantarflexion. CONCLUSION Larger posterior malleolus fractures with osteochondral defects, when loaded with the ankle in neutral and dorsiflexion, resulted in larger tibiotalar articular stresses.

Abstract Physical medicine and rehabilitation clinicians frequently measure the physical functions of their patients with neuromuscular motor dysfunction, such as those recovering from stroke, surgery, or trauma. The Modified Physical Performance Test (MPPT) is a widely accepted measure of physical function. However, the MPPT requires significant time investment from the clinician overseeing the test. Our objective was to create a digital MPPT (dMPPT) based on wearable technology which can be performed without extensive clinician oversight and validate the dMPPT using a clinician directed analogue MPPT (aMPPT). Wearable sensors were developed to capture movements performed in the MPPT. A time score and balance score were calculated for each task. A preliminary clinical trial with ten patients in the inpatient section of a rehabilitation unit was conducted. Patients performed both the aMPPT version without the sensors and the dMPPT with the sensors. We compared scores of the aMPPT with the dMPPT. The Pearson correlation test demonstrated a high (r = 0.99) and significant (p &amp;lt; 0.001) correlation between the aMPPT and dMPPT. Bland–Altman analysis determined that data from all ten participants were within the range defined by the limits of agreement, indicating a high level of practical agreement between the aMPPT and dMPPT. The dMPPT results were significantly correlated and demonstrated a high level of practical agreement with the aMPPT clinician-directed method. Future larger sample clinical trials to validate the dMPPT for clinical use are recommended. With this validation, the dMPPT would allow for more efficient monitoring of patients' physical performance.

Introduction: Neurofibromatosis type 2 related Schwannomatosis (NF2-SWN) is a genetic disorder characterized by the growth of vestibular schwannomas (VS), which often leads to progressive hearing loss and vestibular dysfunction. Accurate volumetric assessment of VS tumors is crucial for effective monitoring and treatment planning. Since tumor growth dynamics are often subtle, the resolution of MRI scans plays a critical role in detecting small volumetric changes that inform clinical decisions. This study evaluates the impact of MRI voxel resolution on the accuracy of manual and AI-driven volumetric segmentation of VS in NF2-SWN patients. Methods: Ten patients with NF2-SWN, totaling 17 tumors, underwent high-resolution MRI scans with varying voxel sizes on different MRI machines at Yale New Haven Hospital. Tumors were segmented using both manual and AI-based methods, and the effect of voxel size on segmentation precision was quantified through volume measurements, Dice similarity coefficients, and Hausdorff distances. Results: Results indicate that larger voxel sizes (1.2 × 0.9 × 4.0 mm) significantly reduced segmentation accuracy when compared to smaller voxel sizes (0.5 × 0.5 × 0.8 mm). In addition, AI-based segmentation outperformed manual methods, particularly at larger voxel sizes. Discussion: These findings highlight the importance of optimizing voxel resolution for accurate tumor monitoring and suggest that AI-driven segmentation may improve consistency and precision in NF2-SWN tumor surveillance.

Background: Trochlear dysplasia is important in recurrent patellofemoral instability (PFI); reliable metrics are essential to understand this condition and help define optimal treatment. One such measurement is the entry point to transition point (EP-TP) angle, which describes 2 components of patellar tracking from full knee extension to flexion: (1) mediodistal movement and (2) pure distal movement. Currently, measurement of this metric relies on 3-dimensional (3D) models. Purpose: To further develop the EP-TP angle metric to allow its digital measurement, to establish cohort and interrater reliability values, and to evaluate its appropriateness for clinical use. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A data set composed of 30 recurrent PFI patient knees and 30 control knees was acquired. Each knee came with anterior views of the distal femur and curvature maps, which highlighted relevant structures such as the trochlear groove and the medial and proximal ridge. Three raters measured EP-TP angles utilizing a digital tool with and without the curvature maps. Significance of differences in means, presence of a TP, and interrater reliability with intraclass correlation coefficients were tested and evaluated according to an established guideline (&lt;0.5, poor reliability; &gt;0.5-0.75, moderate; &gt;0.75-0.9, good; &gt;0.9 excellent reliability). A significance level of .05 corrected with the Bonferroni method was assumed. Results: PFI knees had a significantly higher EP-TP angle than the control cohort (48.9° ± 10.8° vs 11.8° ± 14.6°; P &lt; .001). Patients had a greater TP prevalence than controls (96.7% vs 10.0%). Interrater reliability for the EP-TP angle with curvature maps was significantly better than without (0.84 [95% CI, 0.76-0.89] vs 0.67 [95% CI, 0.55-0.78]; P &lt; .001). Conclusion: The EP-TP angle is significantly different between PFI patients and controls. This study presents a digital approach for measuring the EP-TP angle, in contrast with the initially described method, which required 3D prints. This digital approach, when aided with curvature mapping, yields better reliability.

Orthopaedic nurses play a pivotal role in the collection of social determinants of health (SDOH) data. Therefore, it is crucial to determine orthopaedic nurses' preparedness to address the new SDOH mandates put forward by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC). This study examines nurse awareness and understanding of the new CMS and TJC SDOH requirements for orthopaedic practices. A total of 100 nurses from the National Association of Orthopedic Nurses were electronically surveyed regarding their preparedness for the new CMS and TJC SDOH requirements. Knowledge assessment revealed that 63% of nurses could correctly identify the SDOH domains of the new CMS requirements and 47% of nurses could correctly identify one of the major TJC SDOH mandates. Nurses play a crucial role in screening for SDOH but may need more education regarding the CMS and TJC SDOH mandates.

BACKGROUND: Certain implant combinations change leg length and offset in primary total hip arthroplasty (THA). Poor restoration of leg biomechanics is a frequently cited reason for patient dissatisfaction following primary THA. A pure high-offset stem should provide direct lateralization without affecting femoral length when compared to a standard stem. However, clinical experience with preoperative planning software based on computed tomography-based three-dimensional-models reveals that using pure high-offset stems in THA may cause a difference between expected (no change in femoral length) and actual (small increase) in postoperative femoral length. AIM: To elucidate the causes of these femoral length discrepancies using preoperative planning software. METHODS: Preoperative templating for 43 robotic-assisted THAs, optimizing acetabular size and orientation, center of rotation, stem size and offset, and prosthetic head diameter were obtained. The preoperative planning software was used to calculate differences between preoperative and postoperative femoral length for standard and pure high-offset stems, unique to each patient. RESULTS: = 0.93), 35 femurs (81.4%) experienced a 1-mm increase, and 3 (7.0%) experienced a 2-mm increase in femoral length while using high-offset stem compared to the standard stem. The incidence of femoral length increase was lower for patients with shorter femurs (18/22; 81.8%) compared to patients with longer femurs (20/21; 95.2%). CONCLUSION: When pure high-offset stems were used in preoperative planning software, we demonstrated an unexpected increase in leg length between 1-2-mm in 88.4% of patients. This unexpected increase in femoral length is due to a function of the preoperative planning software's planned stem alignment with the anatomical axis, and not an inherent fault in the stem design. With expanding accessibility of robotic-assisted THA platforms, all potential sources of postoperative leg length discrepancy should be identified during preoperative templating and necessary alterations to the surgical plan should be made to accommodate this unexpected difference when using a pure high-offset stem.

Background: Accurate monitoring of tumor progression is crucial for optimizing outcomes in neurofibromatosis type 2-related schwannomatosis. Standard 2D linear analysis on magnetic resonance imaging is less accurate than 3D volumetric analysis, but since 3D volumetric analysis is time-consuming, it is not widely used. To shorten the time required for 3D volumetric analysis, our lab has been developing an automated artificial intelligence-driven 3D volumetric tool. Objective: The objective of the study was to survey and interview clinicians treating neurofibromatosis type 2-related schwannomatosis to understand their views on current 2D analysis and to gather insights for the design of an artificial intelligence-driven 3D volumetric analysis tool. Methods: Interviews examined for the following themes: (1) shortcomings of the currently used linear analysis, (2) utility of 3D visualizations, (3) features of an interactive 3D modeling software, and (4) lack of a gold standard to assess the accuracy of 3D volumetric analysis. A Likert scale questionnaire was used to survey clinicians' levels of agreement with 25 statements related to 2D and 3D tumor analyses. Results: A total of 14 clinicians completed a survey, and 12 clinicians were interviewed. Specialties ranged across neurosurgery, neuroradiology, neurology, oncology, and pediatrics. Overall, clinicians expressed concerns with current linear techniques, with clinicians agreeing that linear measurements can be variable with the possibility of two different clinicians calculating 2 different tumor sizes (mean 4.64, SD 0.49) and that volumetric measurements would be more helpful for determining clearer thresholds of tumor growth (mean 4.50, SD 0.52). For statements discussing the capabilities of a 3D volumetric analysis and visualization software, clinicians expressed strong interest in being able to visualize tumors with respect to critical brain structures (mean 4.36, SD 0.74) and in forecasting tumor growth (mean 4.77, SD 0.44). Conclusions: Clinicians were overall in favor of the adoption of 3D volumetric analysis techniques for measuring vestibular schwannoma tumors but expressed concerns regarding the novelty and inexperience surrounding these techniques. However, clinicians felt that the ability to visualize tumors with reference to critical structures, to overlay structures, to interact with 3D models, and to visualize areas of slow versus rapid growth in 3D would be valuable contributions to clinical practice. Overall, clinicians provided valuable insights for designing a 3D volumetric analysis tool for vestibular schwannoma tumor growth. These findings may also apply to other central nervous system tumors, offering broader utility in tumor growth assessments.

We present an 81-year-old male who underwent a direct anterior approach total hip arthroplasty (THA) with a ceramic-on-ceramic bearing in 1986. Amazingly, the patient kept meticulous logbooks of his many athletic endeavors, which were tallied after 35 years in 2020. These included 20,797 miles of running, 2323 miles of swimming, 66,349 miles of bicycling, and at least 25,500 miles of walking, amounting to more than 114,969 miles of physical activity. As the average age of patients who undergo index THA decreases, the debate regarding physical activity recommendations after THA has become increasingly relevant for patients, but this topic is inadequately studied and thus remains an unanswered question.

ABSTRACT Surgeons often use long antegrade intramedullary nails (aIMNs) when fixing fractures of the proximal femur in geriatric patients. However, risk of peri‐implant fracture in relation to aIMN termination level has not yet been studied. We therefore studied the correlation between aIMN nail tip termination level and extent of distal femur fracture in three different loading scenarios using finite element models of seven different length aIMNs. These were loaded into 3D models of synthetic osteoporotic femurs, which were loaded in single‐leg stance (SLS) with body weight load at the femoral head, torsion (TOR) counterclockwise to failure with 120 Nm of torque, and distal impact/fall (DIF) simulating direct fall on the knees at 1000 mm/sec. The maximum stress in SLS and percentage of failed elements for TOR and DIF were recorded. For SLS, aIMN tip termination and maximum stress were not correlated ( ρ = 0.1429, p = 0.7599) and there was no apparent trend in the data. For TOR, more proximal aIMN tip termination demonstrated a significant correlation with greater percentage of failed area ( ρ = 0.9286, p = 0.0025). For DIF, aIMN tip termination was not correlated with the percentage of failed elements ( ρ = −0.6071, p = 0.1482), but demonstrated a statistically significant Gaussian relationship (coeffs: = 2.22 ( p = 1.13 × 10 −3 ), = 58.61 ( p = 1.89 × 10 −5 ), = 17.46 ( p = 1.79 × 10 −3 )) where 60 mm aIMN tip termination demonstrated the greatest percentage of failed area. Therefore, we found a strong linear relationship between more proximal aIMN termination in the femur and extent of failure in TOR. There was a statistically significant Gaussian relationship between metaphyseal termination and extent of failure in DIF.

Background: The proximal radius (PR) spans from the radial head (RH) to the bicipital tuberosity. Numerous studies have described this morphology. However, much of the existing work oversimplifies the morphology; for example, modeling the radial neck and/or tuberosity as cylinders, excluding the intramedullary canal (IC) from analysis, and basing models on two-dimensional imaging. The IC is important for radial arthroplasty implant stem selection. The purpose of this study is to quantify the morphology of the PR with a focus on the IC, utilizing the analysis of 3-dimensional models. We stratify the study population into age, sex, and height groups to capture the variance expected in the general population. We hypothesize that IC morphology differs significantly between age, sex, and height groups. Methods: One hundred fifty-one three-dimensional models of the PR and the corresponding ICs were created from CT scans of adult females and males with average height, divided into 3 equally sized age groups (25-30, 40-45, and 60-65 years), and adult females and males of short and tall built. The cross-sections of the first 60 mm of each PR shaft distal to the RH were automatically fitted with ellipses encompassing the external proximal radius (EPR) and the IC at 0.1 mm intervals. From this dataset, we quantified anatomical features relevant for RH arthroplasty, describing the PR and its IC. Results: Females had a smaller and narrower geometry. The PR morphology changed with age and patient height. The PR is eccentric, with the IC being significantly more eccentric. Conclusion: This study finds a wide range in positioning and width of specific anatomical features of the radius relevant to RH arthroplasty implant sizing, which might impact future development of RH implant stems. Furthermore, we found differences related to sex, age, and height of the patient. Both the PR and its IC are eccentric.

BACKGROUND Vestibular schwannomas (VS) are benign tumors that can lead to hearing loss, balance issues, and tinnitus. Gamma Knife Radiosurgery (GKS) is a common treatment for VS, aimed at halting tumor growth and preserving neurological function. Accurate monitoring of VS volume before and after GKS is essential for assessing treatment efficacy. PURPOSE To evaluate the accuracy of an artificial intelligence (AI) algorithm, originally developed to identify NF2-SWN-related VS, in segmenting non-NF2-SWN-related VS and detecting volume changes pre- and post-GKS. We hypothesize this AI algorithm, trained on NF2-SWN-related VS data, will accurately apply to non-NF2-SWN VS and VS treated with GKS. METHODS In this retrospective cohort study, we reviewed data from an established Gamma Knife database, identifying 16 patients who underwent GKS for VS and had pre- and post-GKS scans. Contrast-enhanced T1-weighted MRI scans were analyzed with both manual segmentation and the AI algorithm. DICE similarity coefficients were computed to compare AI and manual segmentations, and a paired t-test was used to assess statistical significance. Volume changes for pre- and post-GKS scans were calculated for both segmentation methods. RESULTS The mean DICE score between AI and manual segmentations was 0.91 (range 0.79-0.97). Pre- and post-GKS DICE scores were 0.91 (range 0.79-0.97) and 0.92 (range 0.81-0.97), indicating high spatial overlap. CONCLUSION AI-segmented VS volumes pre- and post-GKS were consistent with manual measurements, with high DICE scores indicating strong spatial overlap. The AI algorithm processed scans within 5 min, suggesting it offers a reliable, efficient alternative for clinical monitoring. CLINICAL IMPORTANCE DICE scores showed high similarity between manual and AI segmentations. The pre- and post-GKS VS volume percentage changes were also similar between manual and AI-segmented VS volumes, indicating that our AI algorithm can accurately detect changes in tumor growth.

Since orthopaedic nurses often guide patients through pre- and postoperative periods, they play an integral role in fulfilling the new screening requirements released by the Centers for Medicare & Medicaid Services and the Joint Commission. This study aims to highlight measures taken by orthopaedic healthcare organizations to fulfill the 2024 Social Determinants of Health (SDOH) screening requirements. Survey questions were developed and distributed in collaboration with the National Association for Orthopaedic Nurses to assess organizational responses to the requirements. On average, participants rated their institutions' preparedness to screen for SDOH as 3.21, with 30% of respondents ranking their preparedness as a 1 or 2 (5 being "very prepared" and 1 being "not prepared at all"). Organizations should consider developing a written action plan to screen for and address SDOH. They should also consider integrating workflows into the electronic medical record to facilitate easier screening and increase communication between hospital administration and nursing staff surrounding these new requirements.

BACKGROUND In the diagnosis of patellar instability, three-dimensional (3D) imaging enables measurement of a wide range of metrics. However, measuring these metrics can be time-consuming and prone to error due to conducting 2D measurements on 3D objects. This study aims to measure patellar tilt in 3D and automate it by utilizing a commercial AI algorithm for landmark placement. METHODS CT-scans of 30 patients with at least two dislocation events and 30 controls without patellofemoral disease were acquired. Patellar tilt was measured using three different methods: the established method, and by calculating the angle between 3D-landmarks placed by either a human rater or an AI algorithm. Correlations between the three measurements were calculated using interclass correlation coefficients, and differences with a Kruskal-Wallis test. Significant differences of means between patients and controls were calculated using Mann-Whitney U tests. Significance was assumed at 0.05 adjusted with the Bonferroni method. RESULTS No significant differences (overall: p = 0.10, patients: 0.51, controls: 0.79) between methods were found. Predicted ICC between the methods ranged from 0.86 to 0.90 with a 95% confidence interval of 0.77-0.94. Differences between patients and controls were significant (p < 0.001) for all three methods. CONCLUSION The study offers an alternative 3D approach for calculating patellar tilt comparable to traditional, manual measurements. Furthermore, this analysis offers evidence that a commercially available software can identify the necessary anatomical landmarks for patellar tilt calculation, offering a potential pathway to increased automation of surgical decision-making metrics.

INTRODUCTION: Knee osteoarthritis and hip osteoarthritis (OA) are orthopaedic conditions for which total joint arthroplasty (TJA) is the definitive treatment. The correlation of social determinants of health (SDOH) disparities with access to specialized health care such as TJA is of increasing interest. At our institution, SDOH screening was implemented in 2020. The purpose of this study was to identify whether patients with OA who screened positive for SDOH hardship (SDOH positive) were less likely to receive a subsequent TJA. METHODS: Patients with diagnosis of knee or hip OA who underwent SDOH screening from 2020 to 2023 were identified from our institutional record. The correlation of SDOH-positive screening relative to not screening positive (SDOH negative) with the likelihood of receiving TJA was assessed. The incidence of TJA in these two cohorts was evaluated using multivariable logistic regression controlling for age, sex, race, and ethnicity. RESULTS: A total of 2,981 patients were identified fitting the study criteria. The number of SDOH-positive patients was 1,122 (37.6%), and the number of SDOH-negative patients was 1,859 (62.4%). The SDOH-positive group had a significantly lower rate of TJA (9.9% vs. 14.8%, P < 0.0001). When individual SDOH were assessed, transportation insecurity, financial strain, and food insecurity were associated with decreased TJA incidence, with increasing financial strain corresponding to additional decreases in TJA incidence. On multivariable analysis, SDOH-positive status was identified as an independent negative predictor of TJA. DISCUSSION: Patients with knee or hip OA screening positive for SDOH disparities had decreased odds of receiving a subsequent TJA. As screening becomes increasingly more common, these findings illustrate how SDOH disparities correlate with access to orthopaedic care and demonstrate the need for intervention after screening, especially in SDOH categories where organizations can provide resources and support, such as access to transportation and food.

BACKGROUND: Osteonecrosis of the femoral head can be a debilitating disease leading to collapse of the femoral head and the subsequent need for a hip arthroplasty. Core decompression has emerged as a leading treatment to prevent collapse. Adjunctive therapies, such as bone graft, bone marrow aspirate concentrates, or synthetic bone substitutes are utilized to promote native bone regeneration. Determining the amount of bone resected and the volume of adjunct required is challenging, especially with newer minimally invasive reamers. Under- or over-filling the defect may impact progression of the disease or cause morbidity. SURGICAL TECHNIQUE: We introduce a mathematical method to be utilized intraoperatively to calculate the volume of bone resected during core decompression with an expandable reamer. This method approximates the core decompression defect as two cylinders using measurements that can be easily taken during the procedure and can be adapted for use with any of the expandable reamer systems available. Using this technique, surgeons can calculate the size of the defect created, which can be used to personalize the amount of adjunct delivered to each patient. CONCLUSIONS: When adjunctive therapies are used with core decompression to treat ONFH, care must be taken when filling the core decompression defect to avoid under- or over-filling the defect, potentially increasing the risk of complications or reducing the efficacy of the procedure. We provide a simple worksheet that can be used by surgeons to help determine how much adjunct should be used.

Linear and volumetric analysis are the typical methods to measure tumor size. 3D volumetric analysis has risen in popularity; however, this is very time and labor intensive limiting its implementation in clinical practice. This study aims to show that an AI-led approach can shorten the length of time required to conduct 3D volumetric analysis of VS tumors and improve image processing accuracy. From Yale New Haven Hospital and public patient recruitment, 143 MRIs were included in the ground truth dataset. To create the tumor models for the ground truth dataset, an image processing software (Simpleware ScanIP, Synopsys) was used. The helper (DPP V1.0) was trained using proprietary AI- and ML-based algorithms and information. A proof-of-concept AI model achieved a mean DICE score of 0.76 (standard deviation 0.21). After the final testing stage, the model improved to a final mean DICE score of 0.88 (range 0.74-0.93, standard deviation 0.04). Our study has demonstrated an efficient, accurate AI for 3D volumetric analysis of vestibular schwannomas. The use of this AI will enable faster 3D volumetric analysis compared to manual segmentation. Additionally, the overlay function would allow visualization of growth patterns. The tool will be a method of assessing tumor growth and allow clinicians to make more informed decisions.

BACKGROUND: Biomarkers of infection are measurable indicators that reflect the presence of an infection in the body. They are particularly valuable for detecting infections and tracking treatment responses. Previous transcriptome analysis of peripheral blood mononuclear cells (PBMCs) collected from patients during the active phase of diabetic foot infection identified the upregulation of several genes, including a neutrophil-specific cell surface glycoprotein, CD177, an Myb-related transcription factor 2 (MYBL2), and ribonucleotide reductase regulatory subunit M2 (RRM2). We aimed to investigate whether these observations in diabetic foot infections could be extrapolated to other musculoskeletal infections. QUESTIONS/PURPOSES: (1) Are the protein concentrations of CD177, MYBL2, and RRM2 elevated in serum or PBMCs of patients with musculoskeletal infections? (2) Do serum and PBMC concentrations of CD177, MYBL2, and RRM2 decrease in response to antibiotic therapy? (3) Can these biomarkers give diagnostic accuracy and differentiate patients with musculoskeletal infections from controls? METHODS: From April 2023 to June 2024, we treated 26 patients presenting with clinical symptoms and signs of acute musculoskeletal infections, including elevated inflammatory markers (white blood cell [WBC] and C-reactive protein [CRP]) and local changes such as swelling, erythema, tenderness or pain, warmth, purulent drainage, sinus tract, or wound leading to bone or hardware. Diagnosis included periprosthetic joint infection (PJI), foot and ankle infection (FAI), fracture-related infection (FRI), and septic arthritis of the native joints. Patients with chronic recurrent osteomyelitis, PJI, or FRI were excluded from the study. Among the 26 patients deemed potentially eligible, 19% (5) were excluded for the following reasons: prison inmate (1), unable to provide consent because of severe sepsis (1), mental illness (1), and declined to participate (2). Of the 81% (21) of patients who provided consent, cultures from 9.5% (2) were negative. These two patients were ultimately diagnosed with inflammatory arthritis: gout (1) and rheumatoid arthritis (1); thus, the musculoskeletal infection group for analysis consisted of 73.1% (19 of 26) of patients. A control group of 21 patients undergoing elective foot or ankle deformity correction surgery without infections or systemic inflammation was included. Because foot or ankle deformity is highly unlikely to influence the immunologic profile of the subjects, we believed that these patients would serve as an appropriate control group. Other than the absence of infection and the lower prevalence of diabetes mellitus, the control group was comparable to the study group in terms of demographics and clinical factors, including age and sex distribution. We collected blood samples from both patients and controls and quantified CD177, MYBL2, and RRM2 RNA transcription levels in the PBMC using qRT-PCR. We also assessed protein concentrations in the serum and PBMC using an enzyme-linked immunosorbent assay. A comparative analysis of the three biomarkers was performed on 19 patients with musculoskeletal infections with positive cultures and 21 controls to assess their diagnostic potential using the unpaired nonparametric t-test with the Mann-Whitney test. We obtained 8-week follow-up blood samples from seven patients with musculoskeletal infections who clinically healed. Healing was defined by normalization of inflammatory markers (WBC and CRP) and absence of swelling, erythema, local tenderness or pain, warmth, purulent drainage, sinus tract, or open wound. We performed a comparative analysis of the seven patients during active infection and after treatment to determine a change in the level of CD177, MYBL2, and RRM2 in their serum and PBMCs. These findings were also compared with those of the control group. We evaluated the diagnostic accuracy of CD177, MYBL2, and RRM2 for musculoskeletal infections using receiver operating characteristic (ROC) curve analysis. RESULTS: The musculoskeletal infections group showed a larger increased serum and PBMC concentrations of CD177, MYBL2, and RRM2 proteins compared with the control group. The mean protein concentrations of CD177, MYBL2, and RRM2 were increased in the serum and PBMC of the musculoskeletal infections group compared with the controls. Serum levels of all biomarkers investigated were higher in musculoskeletal infections group compared with the control group (CD177 227 [155 to 432] versus 54 [10 to 100], difference of medians 173, p < 0.01; MYBL2 255 [231 to 314] versus 180 [148 to 214], difference of medians 75, p < 0.01; RRM2 250 [216 to 305] versus 190 [148 to 255], difference of medians 60, p < 0.01). Similarly, PBMC levels of all biomarkers were higher in the musculoskeletal infections group (CD177 55.3 [39.1 to 80.5] versus 17.5 [10.5 to 27.5], difference of medians 37.8, p < 0.01; MYBL2 144 [114 to 190] versus 91 [70 to 105], difference of medians 53, p < 0.01; RRM2 168 [143 to 202] versus 100 [77.5 to 133], difference of medians 68, p < 0.01). Additionally, serum levels of all biomarkers decreased in seven patients with musculoskeletal infections after infection treatment (CD177 3080 [2690 to 3320] versus 4250 [3100 to 8640], difference of medians 1170, p < 0.01; MYBL2 4340 [4120 to 4750] versus 5010 [4460 to 5880], difference of medians 670, p < 0.01; RRM2 4350 [3980 to 5000] versus 5025 [4430 to 6280], difference of medians 675, p = 0.01). Similarly, PBMC levels of all biomarkers were lower after infection treatment (CD177 805 [680 to 980] versus 1025 [750 to 1610], difference of medians 220, p < 0.01; MYBL2 2300 [2100 to 2550] versus 2680 [2220 to 3400], difference of medians 380, p = 0.02; RRM2 2720 [2500 to 3200] versus 3350 [2825 to 4030], difference of medians 630, p < 0.01). The area under the ROC curve for diagnosing musculoskeletal infections in the serum and PBMC was as follows: CD177 95% confidence interval [CI] > 0.99 and > 0.99, MYBL2 95% CI > 0.99 and > 0.99, and RRM2 95% CI = 0.96 and > 0.99, respectively. CONCLUSION: We may utilize blood-based tests for CD177, MYBL2, and RRM2 to aid in the diagnosis of musculoskeletal infections, particularly when arthrocentesis or obtaining tissue culture is challenging. They may also assist in monitoring treatment response. As some of these biomarkers may also be elevated in other inflammatory conditions, a large-scale clinical study is needed to confirm their reliability in differentiating musculoskeletal infections from other inflammatory conditions. CLINICAL RELEVANCE: CD177, MYBL2, and RRM2 proteins in blood samples may serve as novel biomarkers for diagnosing and monitoring treatment response in musculoskeletal infections.

Introduction: Demographic disparities in musculoskeletal (MSK) health exist in the US. Racial representation in advertising has been shown to influence consumer behavior and buying patterns. Direct-to-consumer advertising that does not target a racially diverse audience may exacerbate MSK disparities by failing to reach minorities. We explore the hypothesis that minorities are underrepresented in direct-to-consumer MSK advertisements in this cross-sectional analysis. Methods: Using magazines from four databases, eight health-related magazine types were selected and advertisement categories were established. Racial distribution was analyzed using Pearson’s Chi-squared and Chi-squared tests. Fisher’s Exact test was used when &gt;20% of cells had expected frequencies &lt;5. Significance was set at α = 0.05. Results: Of the advertisements featuring at least one model, 68.5% featured a white-presenting model, followed by 17.6% with a black model. Further, 92.7% of advertisements were monoethnic or monoracial with an overrepresentation of white models (p &lt; 0.001). Black models were overrepresented as athletes (p &lt; 0.001) and underrepresented in advertisements for pain relief (p &lt; 0.001). Hispanic/Latinx and Asian models were underrepresented across all advertisement categories (p &lt; 0.001). Discussion: The causes of musculoskeletal health disparities are multifactorial. One potential influence is adjacent industries such as MSK health-related advertisements. When controlling for US population demographics, white models were overrepresented and minority race models were underrepresented, demonstrating racioethnic disparities in MSK advertising. Improving the racial and ethnic diversity of models within MSK advertisements may serve to improve patient perceptions of orthopaedic products and services and improve MSK disparities.

PURPOSE: Given the importance of musculoskeletal knowledge but the limited orthopaedic instruction offered in medical school, our Orthopaedic Surgery Department developed a three-week clerkship for interested students. This study assesses the clerkship's impact on medical student musculoskeletal knowledge through administration of the Freedman and Bernstein Basic Cognitive Musculoskeletal Examination. METHODS: Medical students enrolled in the orthopaedic surgery clerkship between February 2019 and May 2024 were asked to participate in pre- and post-clerkship surveys using the Freedman and Bernstein Basic Cognitive Musculoskeletal Examination. Raw and weighted scores were computed according to the guidelines provided by Freedman and Bernstein. Averaged scores were used to compute mean pre- and post-test scores. RESULTS: There were 64 responses to the pre-test and 33 responses to the post-test. The mean pre-test weighted score was 54% with 12 students (18.8%) passing. The mean post-test score was 70% with 17 students (51.5%) passing. Raw scores showed that musculoskeletal knowledge improved from pre-test (M = 55.13, SD = 19.90) to post-test (M = 70.22, SD = 14.70; p < .001). The results comparing weighted scores showed that the participants' musculoskeletal knowledge also improved from pre-test (M = 52.86, SD = 21.12) to post-test (M = 67.11, SD = 19.02; p < .001). CONCLUSION: While students demonstrated improved musculoskeletal knowledge after completing our institution's orthopaedic surgery clerkship, almost half of the students did not pass the post-test. Most of the students who did not pass the post-test expressed definite or possible interest in pursuing an orthopaedic surgery residency.

<sec> <title>BACKGROUND</title> Accurate monitoring of tumor progression is crucial for optimizing outcomes in NF2-related schwannomatosis (NF2-SWN). Standard 2D linear analysis on MRIs is less accurate than 3D volumetric analysis, but 3D volumetric analysis is time-consuming, so it is not widely utilized. To shorten the time required for 3D volumetric analysis, our lab has been developing an automated AI-driven 3D volumetric tool. </sec> <sec> <title>OBJECTIVE</title> The objective of our study was to survey and interview clinicians treating NF2-SWN to understand their views on current 2D analysis and to gather insights for our 3D volumetric analysis tool's design. </sec> <sec> <title>METHODS</title> Surveys and interviews were conducted with clinicians experienced in treating NF2. Interviews were examined for the following themes: (1) the state of tumor monitoring and 2D analysis, (2) utility of 3D visualization, (3) features for interactive 3D modeling, and (4) lack of a gold standard for 3D accuracy. A Likert scale questionnaire was used to survey clinician’s level of agreement with 25 statements related to 2D and 3D tumor analyses. </sec> <sec> <title>RESULTS</title> 14 clinicians completed a survey, and 12 clinicians were interviewed. Specialties ranged across neurosurgery, neuroradiology, neurology, oncology and pediatrics. Both surveys and interviews revealed concerns around the variability and subjectivity of 2D analysis. Clinicians felt that 3D volumetric analysis addresses these concerns but expressed uncertainty about how it could be interpreted clinically. Clinicians recommended features for the tool, such as interactive 3D models, visualization of neighboring anatomic structures, and the ability to monitor growth using visual cues. </sec> <sec> <title>CONCLUSIONS</title> Clinicians were overall in favor of adoption of 3D volumetric analysis techniques for measuring analyze VS tumors but expressed concerns regarding the novelty and inexperience surrounding these techniques. However, clinicians felt that the abilities to visualize tumors with reference to critical structures, to overlay structures, to interact with 3D models, and to visualize areas of slow versus rapid growth in 3D would be valuable contributions to clinical practice. Overall, clinicians provided valuable insights for designing a 3D volumetric analysis tool for VS tumor growth. These findings may also apply to other CNS tumors, offering broader utility in tumor growth assessments. </sec>

Glucocorticoids (GCs) are the most prescribed anti-inflammatory and immunosuppressive drugs. However, their use is often limited by substantial side effects, such as GC-induced osteoporosis (GIO) with the underlying mechanisms still not fully understood. In this study, we identify Tau as a low-affinity binding receptor for GCs that plays a crucial role in GIO. Tau deficiency largely abolished bone loss induced by high-dose dexamethasone, a synthetic GC, in both inflammatory arthritis and GIO models. Furthermore, TRx0237, a Tau inhibitor identified from an FDA-approved drug library, effectively prevented GIO. Notably, combinatorial administration of TRx0237 and dexamethasone completely overcame the osteoporosis adverse effect of dexamethasone in treating inflammatory arthritis. These findings present Tau as a previously unrecognized GC receptor with low affinity, and provide potential strategies to mitigate a spectrum of GC-related adverse effects, particularly osteoporosis.

INTRODUCTION: Diabetes mellitus (DM) is a common comorbidity in total knee arthroplasty (TKA) patients, which has been associated with multiple complications. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are one class of medications recently approved to better manage DM. This study investigates the correlation of SGLT2i use on postoperative complications and revision rates for diabetic patients undergoing TKA. METHODS: The M157 PearlDiver database was used to identify DM patients undergoing primary TKA. Those prescribed SGLT2i were identified and matched in 1:4 ratio with control DM patients based on age, sex, obesity diagnosis, and Elixhauser comorbidity index. Ninety-day adverse events and 5-year rates of revision were abstracted and compared by multivariable regression, controlling for age, sex, Elixhauser comorbidity index, long-term insulin use, obesity, metformin use, and active tobacco use. RESULTS: A total of 164,474 TKA patients with DM were identified, of which SGLT2i were prescribed for 9,246 (5.6%). On multivariable analysis, SGLT2i use in DM patients was independently associated with higher odds of aggregated adverse events driven by myocardial infarction (odds ratio [OR] 2.40), sepsis (OR 1.81), urinary tract infection (OR 2.10), pneumonia (OR 1.87), and acute kidney injury (OR 1.33) but had lower odds of transfusion (OR 0.31) ( P < 0.0001 for each). On multivariable analysis, 5-year survival to revision TKA were not markedly different between the matched cohorts. DISCUSSION: SGLT2i are being increasingly prescribed for DM patients undergoing TKA. Although they are associated with increased risk of multiple 90-day perioperative adverse outcomes, they are also associated with reduced incidence of blood transfusion. These results may guide surgical decision making and counseling for patients taking this group of medications and align with some prior studies related to glucagon-like protein-1 agonists.

INTRODUCTION: Core decompression is a minimally invasive procedure considered in the treatment of early-stage femoral head osteonecrosis. This procedure is theorized to relieve vascular pressure and promote angiogenesis. Although a less invasive procedure, there are considerations related to learning curve, technique variations, etc. that may affect postoperative complications and longer term adverse events. METHODS: Adult patients who underwent core decompression with a diagnosis of femoral head osteonecrosis were identified in the 2010-Q3 2021 PearlDiver M157 database. Core decompression surgeon volumes over the entire study period were assessed and divided into ranges: low (<5 procedures), medium (5 ≤ x ≤ 19 cases), and high (>19 cases) volumes. A 1:1:1 match based on age, sex, and Elixhauser Comorbidity Index was completed. Rates of 90-day complications were compared with univariable and multivariable analyses. Survival to total hip arthroplasty (THA) and to subsequent hip fracture at both 2 and 5 years were compared by Kaplan-Meier survival analysis. RESULTS: The low-volume, medium-volume, and high-volume surgeon groups made up 87.5%, 11.9%, and 0.2% of core decompression volume, respectively. This was indicative of 6333 patients undergoing core decompression, and matching based on the surgeon-volume category led to 486 patients per group. No statistically significant differences were observed in shorter term complications and survival to THA or hip fracture at 2 or 5 years. CONCLUSION: Core decompression is a treatment option often considered for early-stage osteonecrosis. Critically, no differences were found in rates of any assessed complications between the surgeon-volume matched cohorts. These findings suggest that core decompression is a relatively safe procedure for surgeons of varying volume with this technique. Furthermore, this study suggests that higher volume surgeons are not conducting the procedure with expanded indications that might result in greater rates of conversion to THA.

Lower extremity edema and compression are potential causes of poor soft tissue healing and flap failure for patients who suffer lower extremity trauma. This review summarizes techniques aimed at reducing edema and mechanical pressure in these patients as well as those undergoing soft tissue coverage techniques. We conducted a literature review for postoperative nursing management to reduce edema in the lower extremity, following traumatic injury. To assist orthopaedic nurses in acute care settings, this review presents techniques for reducing edema and mechanical pressure in patients recovering from lower extremity trauma. The accompanying figures demonstrate how to apply these techniques. Techniques such as rope suspension, mini water mattresses, and pillow or blanket stacking were identified as measures that can reduce edema and compression for patients recovering from lower extremity trauma as well as those requiring soft tissue coverage procedures.

Background: Tibial tuberosity–trochlear groove distance (TT-TG) is often used as a primary metric for surgical decision-making in the treatment of patellofemoral instability (PFI), particularly when considering tibial tubercle transfer. Although TT-TG has high interrater reliability, it is prone to measurement differences caused by the alignment of the patient's leg in a scanner gantry, potentially influencing surgical decision-making. Quantification of this error within the clinical literature remains limited. Purpose: To quantify and specify the error in TT-TG caused by leg-scanner alignment by using detailed topographical landmarks and 3-dimensional (3D) analysis of computed tomography scans of patients with PFI. Study Design: Controlled laboratory study. Methods: Three-dimensional models of knees with PFI were created from computed tomography scans and used to identify TT-TG landmarks. TT-TG was measured using the established 2-dimensional (2D) and 3D methods. A model to estimate the differences between these 2 methods was created, and the orientation of the patients’ legs in relation to scanner longitudinal axis was measured to validate this model via linear regression. Interrater reliability was calculated via intraclass correlation coefficients (ICC). Results: A total of 44 knees of patients with PFI were analyzed. Differences between the 2D and 3D methods ranged from -4.0 to 14.7 mm (mean ± SD, 2.7 ± 4.1 mm) with a root mean square difference of 4.8 mm. The TT-TG distance of the 2D method (19.8 ± 7.2 mm) was significantly ( P = .045) longer than that of the 3D method (17.1 ± 4.9 mm). The variance of the 2D method was significantly larger than that of the 3D method. In total, 13 (29.5%) of the knees had a difference of &gt;5 mm between 2D and 3D TT-TG. The estimation model had an adjusted r 2 value of 1.00 and a resulting root mean square difference of 0.21 mm. 3D TT-TGs interrater reliability was good to excellent (ICC, 0.94 [95 CI%, 0.81-0.98]). Conclusion: 3D TT-TG can be used to correct scanner-leg alignment errors, some of which are substantial when using only 2D TT-TG measurements. Clinical Relevance: The findings in this study suggest a need for caution and awareness of the potential effects of differences in alignment of the axes of the leg and scanner when using purely 2D TT-TG as a basis for surgical planning.

Purpose To examine a method to visualize a 3‐dimensional (3D) rendered distal femur using 3D curvature analysis and to compare models of patellofemoral instability (PFI) with controls to study the reliability of the entry point to trochlear groove angle (EPTG) metric. Methods The 3D models of patients with recurrent patellar instability, defined by at least 2 reported patellar dislocation events, and age‐ and sex‐matched controls were created from computed tomography scans. Curvature was calculated to highlight the proximal trochlear ridges and the trochlear groove by overlaying them on the 3D models. Anteroposterior views with and without curvature visualization were created and used for qualitative comparison and to measure the EPTG. The EPTG was measured by 2 raters with and without the aid of the curvature maps. Significant differences between patients with PFI and controls were compared with a Mann‐Whitney U test. Inter‐rater reliability was calculated using interclass correlation coefficients, classified according to literature and compared using a permutation test. Significance was assumed at .05. Results Qualitive analysis between 30 PFI patient knees (age: 23.9 ± 8.4 years, female/male: 24/6) and 30 control knees (age: 21.8 ± 5.6 years, female/male: 22/8) showed that in general, patients with PFI have a lateralized medial ridge and trochlear groove, with the trochlear groove being shorter and shallower. Qualitatively, differences between patients with PFI and controls were significant for measurements both with and without the aid of the curvature maps. Inter‐rater reliability was significantly ( P = .0349) better when using the curvature visualization. Conclusions Curvature‐based visualization aids overlain on a 3D model have the power to increase the information gained from 3D imaging and corresponding 3D models, amplifying their potential value in clinical decision‐making. Such visualizations facilitate both the identification of qualitative differences between patient and control morphology and improve the reliability of the EPTG trochlear dysplasia metric. Level of Evidence Level III, retrospective cohort study.

Background Robotic systems for total knee arthroplasty (TKA) may utilize computed tomography three-dimensional modeling and intraoperative ligamentous balancing data to assist surgeons with implant size and position. This study evaluated the effect of such robotic systems on implant selection. Methods We reviewed 645 TKAs performed with a single prosthetic design at 2 academic medical centers between 2016 and 2022. A robotic system was utilized in 304 TKAs, 341 were conventionally instrumented. Implant sizing was compared between cohorts. Multivariate analyses assessed for confounding and effect modification on the basis of demographics. Results The 2 cohorts exhibited no significant differences in age ( P = .33), weight ( P = .29), or race ( P = .24). The robotic-arm cohort had fewer women (58.9% vs 66.7% P = .04) and was taller on average (66.3 in vs 65.0 in P < .001). Mean polyethylene liner thickness was larger in the manual cohort (10.3 robotic and 10.6 manual; P < .00). On multivariate analysis, robotic-arm TKAs had larger tibial components ( P < .001) and smaller femoral components ( P = .017). Conclusions Robotic-arm assisted TKA with computed tomography–based three-dimensional planning was associated with a larger mean tibial component size and a smaller mean femoral component size when compared to conventionally instrumented TKAs. Observed differences likely reflect differences in the data informing implant size selection; effects on clinical outcomes warrant further study.